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HomeMy WebLinkAboutWally Schmid Excavating 4-14-19 SCHMI02 OP ID: DL "di CORO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/VYYY) 01/15/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 920-734-3110 CONTACT NAME: DAVID VAN BOOGARD ADEMINO GROUP INC. PHONE 920-734-3110 I FAX 920-734-6027 DBA ADEMINO &ASSOCIATES (A/c,No,Ezt): (NC,No): 1001 TRUMAN P O BOX 99 E-MAIL ADDRESS:dvanboogard@ademino.com KIMBERLY,WI 54136-0099 DAVID VAN BOOGARD INSURER(S)AFFORDING COVERAGE — NAIC A INSURER A:SELECTIVE INSURANCE 19259 INSURED WALLY SCHMID EXCAVATING INC INSURER B: 7821 SWISS RD OSHKOSH,WI 54902 INSURERC: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR W POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD VD (MMIDDIYYYYI IMMIDD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR S 2270770 04/14/2018 04/14/2019 DAMAPREMISGE ES TO RENTEDoccurrence) $ 500,000 Y !Ea MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 3,000,000 POLICY X PECOT- X LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER $ COMBINED SINGLE LIMIT 1,000,000 A AUTOMOBILE LIABILITY (Ea accident) X ANY AUTO Y S 2270770 04/14/2018 04/14/2019 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ A X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS LIAB CLAIMS-MADE S 2270770 04/14/2018 04/14/2019 AGGREGATE $ 2,000,000 DED X RETENTION$ 0 $ A WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER _ ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WC 9052201 04/14/2018 04114l2019 E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ A Leased/Rented S 2270770 04/14/2018 04/14/2019 $500 Ded 25,000 Equipment DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CITY OF OSHKOSH & ITS OFFICERS, COUNCIL MEMBERS, AGENTS, EMPLOYEES & AUTHORIZED VOLUNTEERS ARE ADDITIONAL INSURED FOR ONGOING OPERATIONS PER FORM CG7300 &COMPLETED OPERATIONS PER FORM CG2037. CERTIFICATE HOLDER CANCELLATION OSCIT-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF OSHKOSH ACCORDANCE WITH THE POLICY PROVISIONS. 215 CHURCH ST OSHKOSH,WI 54901 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD